Nursing Foundations – NFDN 2005 – Comprehensive Final Exam Review Notes – Canada

NFDN 2003 --- Final questions with accurate answers
Abnormal Posturing Ans✓✓✓ - Decorticate: Flexor posturing (to core)
[add to body] -- adduction
- Decerebrate: Extensor posturing ( Lots of E's) [arms out] -- abduction
- Flacid: absence of motor response


Acid-Base Balance Ans✓✓✓ - Normal pH 7.35 - 7.45
- < 7.30-7.35 acidotic state
- > 7.45 alkalotic state


Acid-Base Imbalances Ans✓✓✓ - ABG
- Based on the carbonic-acid buffer system
- Measures 6 components
- pH, PaCO2, PaO2, oxygen saturation, base excess, bicarbonate
- Deviation from a normal level is indicated by acid-base imbalance


Adrenal Disorders Ans✓✓✓ - Tumors of adrenal glands -
pheochromocytoma 5 "h's" hypertension, headache, hyperhidrosis
(excessive sweating), hypermetabolism, hyperglycemia
- Addison's disease - adrenocortical insufficiency - adrenal cortex
function is inadequate to meet clients need for cortical hormones.
Increased potassium levels, low sodium levels (chronic dehydration)
- Addisonian crisis - acute hypotension and hyperkalemia may become
life threatening

,Adrenal Glands Ans✓✓✓ - 2 glands
- Upper portion of kidneys
- Adrenal medullla releases adrenaline
- Adrenal cortex release adrenocortical sectretions that make it possible
for the body to adapt to stress.


Alteration of Parathyroid Glands Ans✓✓✓ - Hyperparathyroidism -
overproduction of parathyroid hormone leads to bone decalcification and
development of renal calculi
- Hypoparathyroidism - inadequate secretion of parathyroid hormone
lack of blood flow or surgical removal results in decreased resorption of
calcium from bone through the renal tubules causing hypocalcemia -
muscle tetany (tremors spasms) Trousseau's sign + carpopedal spasms of
wrists, feet, fingers and toes.
- Chvostek's sign - tap over facial nerve causes twitch of mouth nose and
eye


Alterations of Pituitary Ans✓✓✓ - Simmonds' disease: hypopituitarism
- Sheehans's syndrome: postpartum pituitary necrosis due to excessive
blood loss at birth
- Cushing's syndrome or acromegaly: hypersecretion of ACTH or
growth hormone
- Diabetese insipidus: deficient production of ADH
- Syndrome of Inappropriate antidiuretic hormone secretion - excessive
growth hormone

,Altered Neurological Function Ans✓✓✓ - Head/scalp/brain injury:
Closed (blunt) brain injury-head collides, Open brain injury-object,
penetrates skull and damages brain, Concussion-temp loss of
neurological fx without structural damage, Contusion-bruised brain,
Diffuse Axonal injury-damage to axons in cerebral hemispheres, corpus
callosum and brain stem, Intracranial hemorrhage, Epidural hematoma
(extraural hematoma or hemorrhage), Subdural hematoma, Intracerebral
hemorrhage and hematoma
- Spinal Cord Injury-paraplegia, quadriplegia
- Problems-Primary-contusions, lacerations. Secondary-brain swelling,
bleeding, ICP -- ABC problems, ineffective airway clearance, Increased
volume of fluid in head due to swelling = increased ICP/restriction of
blood flow and decreased O2 = schema = infarctions = irreversible brain
damage/death


Assessment of Fluid Balance Ans✓✓✓ - Health history [age, acute
illness, environmental factors, diet, medications]
- Physical exam [head to toe, weight [1kg gain = 1L fluid gain],
intake/output, assess edema, diagnostic tests]


Assessment of mobility Ans✓✓✓ - Skeletal: score each muscle on 0-5
scale
5 = Normal ROM with full resistance
4 = Good ROM - some resistance
3 = Fair ROM - against gravity
2 = Poor ROM - no gravity
1 = Trace ROM - slight muscle contractility

, 0 = Zero -NO muscle contractility


Assessments of General Mobility Ans✓✓✓ - Health history, current
condition, chief complaint - PAIN, inflammation, weakness
- Risk Factors: 1.Lifestyle-Activities, Recreation, Diet, Exercise,
2.Environmental-Workplace, Home, 3. Developmental-Children, Young
Adults, Older Adults, 4. Physiological - Musculoskeletal, Neurological
- Physical Examination: Body alignment, gait, joints and skeletal
muscles. Use your observation skills. Kyphosis, scoliosis, lordosis
Gait - Observe patient ambulating - slow, stiff, limps. Joints
Put patient through ROM - especially extremities as need these for
ADLs. Eg sore shoulders = can't do hair, back zippers.
Skeletal muscles-muscle strength


Assessments/Diagnostics of Endocrine Ans✓✓✓ - Diagnosis of
diabetes is based on elevated plasma glucose levels with /without
symptoms
- Fasting plasma glucose (FPG)
- Casual plasma glucose (Casual PG)
- Oral glucose tolerance test (OGTT)
**** A1CN = hemoglobin = to confirm a diabetic


Assisting w/ ADL's Ans✓✓✓ - Bath or shower:always wrap IV site
- Changing a gown: keep IV bag above insertion site
- Ambulation: hand with the IV no higher than the waist